Delta Inflation and Other Problems With Trials - Scott AbereggSMACC Conference
This document discusses epistemic problems in critical care medicine research. It notes that for interventions with less obvious or immediate effects, evidence from clinical trials is important due to uncertainty. However, many such trials in critical care have problems with non-repeatable positive results and inadequate study power to detect realistic treatment effects. This leads to a situation where the null hypothesis of no treatment effect has stochastic dominance. The document argues that commonly used research practices like setting a low threshold for statistical significance, aiming for high study power, and accurately estimating expected treatment effects are often not followed, undermining the strength of evidence even from large trials.
Resume menjelaskan tentang pengawasan K3 mekanik, termasuk pengertian, dasar hukum, ruang lingkup, pencegahan kecelakaan kerja, sumber bahaya dari pesawat tenaga dan produksi serta pesawat angkat dan angkut, syarat-syarat K3, pemeriksaan dan pengujian. Tujuan pengawasan K3 mekanik adalah meningkatkan keselamatan dan kesehatan kerja di tempat kerja yang menggunakan mesin.
Leptomeningeal carcinomatosis is the infiltration of malignant cells into the leptomeninges, which is the protective layers surrounding the brain and spinal cord. It occurs in 5% of cancer patients and most commonly spreads from primary cancers of the breast and lung. Clinical presentation involves neurological symptoms affecting the brain, cranial nerves, and spinal cord. Diagnosis is made through lumbar puncture and imaging of the craniospinal axis. Treatment aims to palliate symptoms and improve survival through radiotherapy targeting symptomatic areas and CSF flow pathways. Craniospinal irradiation provides wider treatment but is associated with acute and late toxicities. Localized radiotherapy to specific sites offers additional palliation with reduced side effects.
Money and technology…goodness, wouldn’t it be great to have lots of both? In the words of a famous science fiction writer, William Gibson, “..The future has arrived—it’s just not evenly distributed yet.” In other words, off-the-shelf techniques and equipment exist to take airway management to the next level. Do we need “new” equipment, or do we need a “new” plan to use the existing equipment? Let’s briefly discuss both recent new technologies and some new plans.
Approximately 5 months after this lecture was delivered at SMACC 2015, the Difficult Airway Society of Great Britain (DAS) published its revised guidelines on difficult airway management (coinciding with the World Airway Meeting in Dublin, Ireland in November 2015). The new guideline was simple, straightforward, and relied on the major planning points of a 4-step progression from “ plan “A” (intended to represent a best initial approach to plan “D”, representing the prompt performance of a surgical airway. “A-B-C-D” is thus the progression of the DAS plan. What is interesting about the DAS guideline is:
#1—The lack of readiness of most Emergency Medicine and Critical Care practitioners to formulate and implement a plan “B” (Use of Supraglottic airway for ventilation rescue and as an intubation conduit), and
#2—The lack of applicability of plan “C” to the same group, namely, the possibility of allowing the patient to awaken from anesthesia should an airway attempt prove unsuccessful.
The lecture on the Airway Toolbox pays homage to the great “Plan B”, the legacy of the brilliance of the creator of the Laryngeal Mask Airway and all the brilliant clinicians who developed the techniques to make these types of Supraglottic airways quite potentially the most solid method of difficult airway management that will ever grace the planet. As an add on to SGA’s, consider the use of video endoscopy (bronchoscopy or video stylets) to assist DL and VL.
Colloid solutions have been extensively used during resuscitation of shock patients. They were often selected over crystalloid solutions because of their expected ability to expand plasma volume faster than crystalloids and at a lower volume.
Recent data from high quality trials have questioned the superior efficacy of colloids over crystalloids and shown clear side-effects of colloids in critically ill patients. Thus hydroxyethyl starch has been shown to increase the risk of kidney failure, bleeding and mortality in critically ill patients. Albumin has been associated with increased mortality in patients with traumatic brain injury. Therefore, current guidelines do not recommend choosing colloids over crystalloids.
In spite of this, there appears to be a continued use of albumin solutions in intensive care patients. The reasons for this are unknown. It may be that clinicians still believe in the colloid theory, a belief that made be supported by observations of the albumin trials in intensive care patients, including small differences in potency and results of sub-group analyses. However, albumin is a limited and expensive resource and its use is not supported by high-quality data.
Hemorrhage is the leading cause of preventable death following trauma. Non-compressible hemorrhage is of particular concern as these patients require emergent intervention and many will die prior to anatomic hemostasis. For years, left anterior thoracotomy, the “ED thoracotomy”, was the standard of care for temporary proximal aortic occlusion, but survival remained dismal. Endoluminal aortic occlusion which was actually first described in the 1950s. With the increasing use of endovascular therapies for a wide variety of vascular disease, the “REBOA” (Resuscitative Endovascular Balloon Occlusion of the Aorta) began to be reported for use for ruptured abdominal aneurysms in the 2000s. Since that time, interest in its use in trauma has been increasing with a variety of basic science studies and early clinical series and case reports documenting potential benefits. Although no large randomized trials, or even large observational studies, are available, use of the REBOA is considered standard of care in many centers. Typically the REBOA is placed via the femoral artery either percutaneously or via a cut down and the aorta is occluded with a balloon placed over a wire by standard Seldinger-type technique. The balloon can be placed in “zone 1” just above the diaphragm to provide occlusion to the abdominal viscera and pelvic vasculature or in “zone 3” at the aortic bifurcation to provide inflow control to the pelvis and lower extremities. Injuries are then addressed and the balloon is carefully deflated taking care to avoid metabolic collapse from reperfusion. One main limitation of this technique is that the currently approved device in the United States requires a 12F sheath which requires an open femoral artery repair which obvious can be associated with significant complications. There are a huge number of unanswered questions about the use of REBOA in 2015:
1. Who are the appropriate patients in whom use may be beneficial?
2. How long can a balloon be inflated and the aorta be occluded before irreversible ischemic damage to the viscera occurs?
3. How long can the aorta be occluded before the metabolic consequences of reperfusion are lethal?
4. What is the effect on cerebral and cardiac perfusion when a REBOA is placed and afterload is acutely increased? Is it favorable or “too much”?
5. Who are the appropriate providers to place a REBOA? Only surgeons? Emergency Medicine physicians? Medics in the field?
6. How do we best train providers to place the REBOA?
7. How to we assure competency of providers?
8. Will lower profile devices make the technique more accessible and be associated with fewer complications?
Medicine for Mars - Kevin Fong
Summary by: Kevin Fong
Kevin Fong is an astrophysicist, astronaut and anaesthetist who gives an incredibly entertaining talk about human space exploration and our dreams of a manned mission to MARS. This is a mission that stands on the boundary between science fiction and science fact. A mission that would be a minimum of 1000 days in length and which would be twice as long as any previous manned space mission.
Fong focuses on the the incredibly destructive effects of such prolonged weightlessness on the human body. He outlines the somewhat predictable effects of this on the muscles and bones, but surprises us with the changes in vestibular balance, linear acceleronomy, baroreceptor calibration and probably most frighteningly the psychological effects of prolonged isolation in space. Despite considerable work in the area of human adaptation for space and the ongoing development of counter-measures these physiological challenges remain largely unsolved.
In essence Fong explains, to overcome the detrimental physiological effects of prolonged weightlessness engineers need to design a craft capeable of generating 1G of gravitational force to mimick earth’s gravity. This could require a craft the size of the London EYE rotating four times per minute. Perhaps if this can be achieved, astronauts might arrive at MARS after 30 months in space in a physcial state capeable of allowing them to stand upright and walk from the landing craft.
Managing the Transected Airway by Georgie HarrisSMACC Conference
The management of the transected airway is frightening because it is a rare airway emergency and one that does not fit the usual plan A,B,C airway management algorithms. An approach is presented which considers two principal anatomical distinctions for injuries both above and below the cricoid cartilage.
Secondly, the mechanism of injury is classified according to whether it is either penetrating or blunt trauma. Finally the airway management urgency is described according to either an immediate or semi-urgent approach being required. These three approaches, the location of the injury relative to the cricoid, the mechanism of the injury and thirdly, the urgency of the airway intervention required are then applied together to provide a guide to management of the transected airway.
ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest.
In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes.
He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre.
In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive.
Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.
When to stop resuscitation in probably the biggest question challenging Critical Care and it's a challenge that many of us face virtually every clinical shift. The main problem is that there is little good data to guide us, leaving us to navigate this situation with few coordinates to plot a path forward. When to stop resuscitation explores this problem and suggests some landmarks we can use to navigate by. It examines the inter-relationship between the pillars of our medical ethics Autonomy, Beneficence, Non-Maleficence and Justice. To better understand the clinical challenges we face, the talk also uses a framework provided by modern physics and the 'Space Time Continuum' theorem. Hence the title might more appropriately be – “The will to Live – The courage to die and the space-time continuum”.
If the thought of how Einstein’s theorem on ‘General Relativity’ can help us answer the question of, when to stop resuscitation interests you then don’t miss this.
This document discusses pediatric simulation training and critical care education. It acknowledges contributors to the field and emphasizes integration and collaboration across specialties. The document outlines the patient journey from injury to rehabilitation and stresses the importance of multi-professional education from undergraduate to post-graduate levels. It promotes using simulated pediatric patients and families to engage clinicians and advocates for primary injury prevention. The document poses questions and challenges educators to train healthcare professionals in teams using simulated patients from the start of their education.
Образовательные: закрепление и обобщение знаний учащихся полученные при изучении темы, отработка умений и навыков по решению квадратных уравнений различного вида различными способами, выработка умения выбрать нужный рациональный способ решения.
Развивающие: развитие логического мышления, памяти, внимания, умений сравнивать и обобщать, умения выступать с самостоятельными суждениями и отстаивать их.
Воспитательные: воспитание трудолюбия, взаимопомощи, математической культуры, умение работать в группах.
1. Контрольная работа
по теме: «Тригонометрия»
II – вариант
1. Найти cos x , если sin x = 0<x<
2. Доказать тождества:
a) 1 + tg2α + =
b) sin2α + ctg2α + cos2α =
3. Решить уравнение:
2cos x + = 0 и найти корни принадлежащие промежутку [0;2π]
4. Решить уравнение:
2sin – =0
5. Решить уравнение:
sin x + cos(2π + x) – cos ( - x) = - 1
6. Решить уравнение:
2sin2x + 7 cosx + 2 = 0
7. Решить уравнение:
( sin x + 1)2 = sin2x + 1
8 . Решить уравнение:
3sin2x + sin x cos x = 2 cos2x
9 sinx cosx – 7 cos2x = 2 sin2x
2. Контрольная работа
по теме: «Тригонометрия»
II – вариант
3. Найти sin x , если cos x = <x<
4. a) 1 + tg2α + =
b) sin2α + ctg2α + cos2α =
3. Решить уравнение:
2cos x + = 0 и найти корни принадлежащие промежутку [0;2π]
2 Решить уравнение:
2sin – =0
3 Решить уравнение:
sin x + cos(2π+x) – cos ( - x) = - 1
4 Решить уравнение:
cos 9x - cos 7x + cos 3x – cos x = 0
7. Найти значение выражения 4cos2x + 2, если sin 2x = 0,6.
8. Решить уравнение:
sin2x = cos4 - sin4
9. Решить неравенство:
сos22x – sin22x ≥ -
10. Решить уравнение: sin2x – 2sin x cos x = 3 cos2x